Get Loss And Theft Report Form

Filling out the Loss And Theft Report Form is essential for reporting incidents involving controlled substances and precursors. This guide will provide you with clear, step-by-step instructions to complete the form accurately and efficiently online.

Follow the steps to fill out the Loss And Theft Report Form online.

1. Click ‘Get Form’ button to begin obtaining the Loss And Theft Report Form. This action will open up the form in your digital workspace.
2. Enter the name of the establishment that has experienced the loss or theft. This should be the official name of the licensed dealer, pharmacy, hospital, etc.
3. Input the date of discovery. This should reflect the exact day you became aware of the loss or theft as per regulatory requirements.
4. Type in the complete street address of the establishment. Ensure that this address matches the official documentation.
5. Provide a telephone number where a contact person can be reached for any inquiries regarding the incident.
6. Select the type of establishment from the provided options. If your establishment does not fit into any of the predefined categories, choose 'Other' and specify.
7. Identify the type of loss or theft. Select one from the list provided, ensuring that you're clear on what occurred. If none fit, choose 'Other' and explain.
8. Indicate whether you have reported the incident to the police. If yes, provide the details, including the name of the police service and the incident number.
9. For losses that occurred in transit, state the name of the transport company responsible for shipment.
10. List the controlled substances and/or precursors that were lost or stolen, ensuring to include the trade name, unit strength, dosage form, unit of measurement, and quantity.
11. Provide the Drug Identification Number (DIN) or Natural Product Number (NPN) if available, or the lot number for the product.
12. Detail the circumstances surrounding the loss or theft, including any security measures that were in place and any changes made to prevent future incidents.
13. Append any required documentation such as copies of reports submitted to the police.
14. Ensure the form is signed by the designated official, and include their name, title, license number, and date of submission.
15. Once completed, you can save the changes, download a copy, print it out, or share the form as needed.

Take action now and fill out the Loss And Theft Report Form online to ensure proper reporting of your incident.